It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development. Summary We are seeking a talented individual for a DRG Nurse Quality Auditor, Sr. Specialist who is responsible for performing on-going quality assurance audits of the accuracy and consistency of work performed by clinical and coding staff. Responsibilities include performing DRG validation (clinical/coding) reviews of medical records and/or other documentation to validate the conditions that were documented in the medical record, the ICD-10-CM/PCS code assignments and determine the accuracy of DRG assignment that is clinically supported as defined by review methodologies specific to the contract for which review services are being provided. This involves accessing proprietary systems to audit medical records, accurately documenting findings and providing policy/regulatory support for determination. The candidate must have extensive clinical experience and an active coding certification with a background in auditing medical records with a high level of understanding payment methodologies including MS-DRG, and APR-DRG. What you will do - Conducts QA audits to ensure accurate determinations and high-quality documentation. - Identifies quality trends and develops corrective education and training. - Reviews medical records for accurate coding, compliance, and guideline adherence. - Applies job aids, policies, and criteria consistently during reviews. - Documents review decisions clearly for reporting and trending. - Meets productivity and quality standards while completing all review elements accurately. - Supports and trains new reviewers, coders, or clinical DRG auditors as needed. - Demonstrates strong knowledge of payment methodologies, DRG validation, and client-specific requirements. - Maintains current knowledge of coding guidelines, licensure, and CEU requirements. - Participates in trainings, cross-trains on claim types, and supports projects, analysis, and reporting. - Serves as a subject matter expert as needed. What we're looking for - Associates degree required; bachelor’s degree preferred. - Active, unrestricted RN licensure from the United States and in the state of primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required - One of the following Coding Certifications required: RHIA, RHIT, CCS, CIC, CCDS or CPC - 5+ years clinical experience in an inpatient hospital setting required - 3+ years of MS DRG/APR DRG coding or auditing experience with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies - Expert knowledge of ICD -10-CM coding including but not limited to; expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM) - Expert knowledge of ICD-10-PCS coding methodologies, code sequencing, and discharge disposition in accordance with CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance. - Demonstrated ability to apply clinical review judgment to make clinical determinations - Excellent written communication skills including ability to write clear, concise, accurate, and fact-based rationales in support of review determinations. - Advanced knowledge of medical codes, coding conventions and rules. - Demonstrated experience in medical review, chart audits and quality improvement processes. What you should expect in this role - Remote within the U.S. - 0–10% travel required Applications for this posting will be accepted until April 24, 2026. The pay range for this position is $85,000.00 - $102,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.

• The Attorney Auditor reviews legal and non-legal invoices on behalf of our clients for services provided to insurance carriers, corporate legal departments and government entities. • The auditor will apply client specified billing guidelines and/or Generally Accepted Principles and Standards (“GAPS”).

• This role is part of the training team for the Clinical Chart Validation team. • This position is responsible for improving the technical effectiveness of our teams by planning, developing, and delivering technical training, mentoring, and assessment. • The individual will work collaboratively with subject matter experts in the Commercial & Government Audit Teams, Quality Assurance, Concept Development, and others to validate workflows and communication tools to enhance audit productivity, performance, and client satisfaction. • Assess job-specific needs and develop technical training plans with clear business objectives, including working with subject matter experts, developing training materials, and developing appropriate assessments and measurements of success. • Select training/instructional methods and procedures appropriate for the situation when learning or teaching new skills. • Deliver specific training sessions, including using suitable delivery methods such as classroom, online, and webinar. • Identify the development needs of others and coach, mentor, or otherwise assist others with improving their knowledge skills. • Provide support to the CCV audit team members; assist with orientation of new members as needed, mentor new team members after orientation. • Promote audit accuracy measures by training/educating and mentoring the auditor and providing documented and validated findings. • Encourage critical thinking and discussion among team members on concepts as needed. • Provide training on one or more of the following audit types: Outpatient and Specialty Review Types to include SNF, IRF, and HH. • Train Clinicians with coding certifications on coding principles. • Confer with management and conduct surveys to identify training needs based on projected production processes, changes, and other factors. • Participate in weekly/monthly team meetings to share best practices initiatives and recommend audit vulnerabilities. • Support the Medical Director to ensure accurate assessments of improper payments are based on consistent application of clinical guidelines. • Assess customer/provider/stakeholder issues, complaints, and compliments. • Monitor/Assess the performance of self, other individuals, &/or organizations to make improvements or recommend remediation or corrective action. • Work with the Quality Team to train audit team members on findings from quality review audits. • Develop testing and evaluation procedures. • Evaluate instructor performance and the effectiveness of training programs, providing recommendations for improvements. • Conduct or arrange for ongoing technical training and personal development classes for staff members. • Integrate healthcare auditing principles and use objectivity in the performance of medical audit activities and reviews. • Draw on healthcare proficiency and industry knowledge to substantiate conclusions. • Perform work independently, review and interpret audit work of others. Depending on the nature and scope of the audit, may review medical records and apply in-depth knowledge of clinical criteria to determine medical necessity, appropriateness of setting, potential billing/coding issues, and quality concerns. • Demonstrate an understanding of complex contract specifications when performing medical record reviews. • Use healthcare expertise to determine approval or referral to the Medical Director. • Provide feedback on reviews to the Quality Assurance Manager as indicated in order to assist with the improvement of rationales sent to providers. • Develop reasonable and effective recommendations for concept solutions that reflect an understanding of the client environment and risks inherent to our business and industry. • Suggest and or develop and implement new ideas, approaches, decision trees, and/or technological improvements that will support and optimize audit results. • Collaborate with Data Services in developing new reports. • In addition to regular and predictable attendance, maintain production goals and quality standards set by the audit. • Performs QA audits against the expected level of quality and quantity (i.e. hit rate, # claims written, ID per hour).

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Responsible for performing audit and abstraction of medical records (provider and/or vendor) to identify and submit ICD codes that are submitted to the Centers for Medicare and Medicaid Services (CMS) for the purpose of risk adjustment processes are appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures. - Proven ability to support coding judgment and decisions using industry standard evidence and tools. - Proficient in abstraction and assignment of accurate medical codes for diagnoses as documented by physicians and other qualified healthcare providers in the office and/or facility setting. - Sound knowledge of coding guidelines and regulations to meet compliance requirements, such as establishing medical necessity. - Identify clinically active vs. historical conditions - Diagnosis codes must be appropriate, accurate, and supported by clinical documentation in accordance with all State and Federal regulations and internal policies and procedures. - Utilize medical records to ensure support is documented for etiology and manifestations of disease processes. - Adhere to stringent timelines consistent with project deadlines and directives. - Conducts self- process audits to ensure compliance with internal policies and procedures as well as regulatory guidance from CMS, OIG or other Regulatory body. Required Qualifications - Minimum of 1 year recent and related experience in medical record documentation review, diagnosis coding, and/or auditing. - CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist-Physician) required. - Computer proficiency including experience with Microsoft Office products (Word, Excel, Access, PowerPoint, Outlook, industry standard coding applications Preferred Qualifications - Completion of AAPC/AHIMA training program for core credential (CPC, CCS-P) with associated work history/on the job experience equal to approximately 1-2 years for CPC. - Experience with Medicare and/or Commercial and/or Medicaid Risk Adjustment process and Hierarchical Condition Categories Education - AA/AS or equivalent experience Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $18.50 - $38.82 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments. We anticipate the application window for this opening will close on: 04/14/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.